Incidence, Risk Factors and Outcomes of Sepsis in Post-Craniotomy Critical Ill Patients

doi:10.21203/rs.3.rs-423595/v1

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Incidence, Risk Factors and Outcomes of Sepsis in Post-Craniotomy Critical Ill Patients

https://doi.org/10.21203/rs.3.rs-423595/v1

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posted 19 Apr, 2021

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Background: Data about the epidemiology of sepsis in post-craniotomy critical ill patients are scarce. This study aims to assess the incidence, risk factors, and outcomes of sepsis in this population.

Methods: We conducted a prospective cohort study between January 1, 2017, and December 31, 2018, in the intensive care unit (ICU) of Beijing Tiantan Hospital. Patients admitted to ICU after intracranial operations and meeting the inclusion criteria were screened daily for the presence of infection and sepsis. We also collected demographics, primary diagnosis, chronic comorbidities, information about surgery, infection, and patients’ outcomes.

Results: Of the 900 included patients, 509 (56.6%) were with infection, and 300 developed sepsis. The cumulative incidence of sepsis was 33.3% [95% CI, 30.2%-36.4%]. Male sex, older in age, supratentorial surgery, the sellar region tumors, postoperative hydrocephalus, higher Acute Physiology and Chronic Health Evaluation (APACHE) II score, higher Sequential Organ Failure Assessment (SOFA) score, and lower Glasgow Coma Scale (GCS) were independent risk factors of sepsis. Sepsis was associated with a higher hospital mortality rate (13.7% vs. 8.3%, p =0.012), lower Glasgow Outcome Scale (GOS) at discharge (3 vs. 4, p<0.001), longer ICU length of stay (LOS) (14 vs. 4 days, p<0.001), longer hospital LOS (31 vs. 19 days, p<0.001), and higher total medical costs (RMB 138,394 vs 75,918 Yuan, p<0.001).

Conclusions: Sepsis is a frequent complication in post-craniotomy critical ill patients, and is associated with increased hospital mortality rate, increased hospital costs, prolonged ICU LOS, and hospital LOS.

Trial registration: Clinicaltrials.gov number: NCT03803813

Critical Care & Emergency Medicine

sepsis

post-craniotomy

incidence

outcome

risk factors

Post-craniotomy patients are susceptible to central nervous system (CNS) infection, which is associated with craniotomy procedure, placement of drainage tubes or other intracranial devices[1, 2], as well as post-operation complications, such as leakage of cerebrospinal fluid [1]. Furthermore, intensive care unit (ICU) admitted neurosurgical patients are often bedridden, immobilized, or disturbed consciousness and swallowing dysfunction [3, 4]. These factors also make these patients vulnerable to extra-CNS infection, particularly pulmonary, urinary tract, and bloodstream infection [5, 6].

Sepsis is an organ dysfunction syndrome caused by the dysregulation of the body's inflammatory response to infection and is associated with higher mortality rates and prolonged hospital stays [7–10]. It is still a major challenge for ICU clinicians because of its high and increasing incidence and clinical complexity. There have been numerous epidemiologic sepsis studies focused on medical or surgical patients [7–9, 11–18]. Zaid et al.[19] and Berger et al [20] have reported the incidence and prognosis of sepsis in neurological patients. However, these studies only included stroke patients. Published data about sepsis in post-craniotomy critical ill patients are scarce.

In this prospective cohort study, we assessed the incidence, risk factors, and sepsis outcomes in ICU admitted post-craniotomy patients. Our goal is to describe the epidemiology of sepsis in this population, help clinicians identify high-risk patients, achieve early diagnosis and treatment of sepsis, and improve the prognosis of patients.

Study design

We conducted this prospective cohort study in the ICU (70 beds) of Beijing Tiantan Hospital. The study was approved by the institutional review board of Beijing Tiantan hospital, with a waiver of informed consent as there was no intervention in this study (approval number: KY2019-046-01).

All adult (age ≥ 18 years) post-craniotomy patients admitted into ICU during the study period (from January 1, 2017, to December 31, 2018) were eligible for screening. We excluded patients who stayed in ICU for less than 24 hours or developed sepsis before the operation. All of the patients were screened daily for the presence of infection and sepsis. In our unit, a standard protocol was established to diagnose sepsis according to the definition of sepsis 3.0 [21–23]. For patients with multiple episodes of sepsis during the same hospitalization, only the first episode was counted.

Data Collection

Data were collected using case report forms (CRF) and were double-entered by two ICU physicians. All recorded data were screened in detail by medical personnel for missing information, logical errors, or insufficient details. Inconsistencies were resolved by an interview with the physicians in charge of collecting the data. Two chief physicians checked the eligibility criteria, characteristics of infection, and diagnosis of sepsis.

At the study entry, demographic data, primary diagnosis, chronic comorbidities, and Charlson comorbidity index [24] were recorded. Information about surgery (operation time, surgical site, indwelling drainage tubes, complications) and infection (origin of primary infection and microbial culture results) were also collected. Acute Physiology and Chronic Health Evaluation (APACHE) II score [25], Sequential Organ Failure Assessment (SOFA) score [26], and Glasgow Coma Scale (GCS) was used to assess the severity of the disease. Patients were followed up until discharge or death, whichever came first. Hospital length of stay (LOS), ICU LOS, hospital costs and hospital mortality rate, and Glasgow Outcome Scale (GOS) were calculated. Patients readmitted into the hospital during the study period would be screened again. For patients with multiple sepsis during the same hospitalization, only the first sepsis episode was counted.

Definitions

Sepsis and septic shock were defined according to the sepsis-3 criteria [21–23]. Infection was determined by the attending physicians as the presence of polymorphonuclear cells in normally sterile body fluid(except blood), positive culture or Gram stain of normally sterile body fluid or tissue[27], unquestionable clinical signs of infection, such as fecal peritonitis, necrotizing fasciitis, wound with purulent discharge et al., or clinically suspected infection(anatomical and/or by imagery and/or histological evidence) with corresponding antibiotic treatment. CNS infection referred to meningitis, ventriculitis, brain abscess, subdural empyema, and epidural empyema. Meningitis/ventriculitis was defined by organisms present on cerebrospinal fluid (CSF) culture or the presence of clinical symptoms and signs (such as fever, new headache, change in mental status, new meningeal signs, cranial nerve signs) and CSF abnormalities (an increased opening pressure, the presence of polymorphonuclear pleocytosis, decreased glucose, and increased proteins deemed not to be chemical meningitis) or organisms seen on Gram’s stain of CSF[28]. Brain abscess, subdural empyema, and epidural empyema were diagnosed by magnetic resonance imaging (MRI) or computed tomography (CT) with contrast and confirmed by positive culture of needle aspiration and open drainage specimens. Infections that occurred 48 hours or more after admission and might not be incubating at the time of admission were defined as nosocomial infections[29].

Statistical analysis

Continuous variables were expressed as mean (SD) and analyzed by unpaired Student's t-test. Nonparametric variables were expressed as median and interquartile range and analyzed by the Mann-Whitney U-test. Categorical variables were presented as absolute (n) and relative frequency (%) and were analyzed by chi-square test or Fisher exact test, as appropriate. The risk factors of sepsis were evaluated by logistic regression analysis. Variables with p values lower than 0.2 by univariate analysis were entered into the model, and the Hosmer-Lemeshow test was used to assess the calibration of the regression model. All comparisons were unpaired. Two-tailed p values < 0.05 were considered statistically significant for all comparisons. SPSS version 19.0 for Windows software was used for the statistical analysis.

Incidence of sepsis

During the two-year study period, 6,471 patients were admitted into our ICU, including 6,061 post-craniotomy patients. A total of 5,161 patients were excluded (Fig. 1), and 900 patients were included and screened, among whom 55.3% were male, and 45.7% were female; 78.1% underwent elective surgery, and 21.9% underwent emergency surgery (Table 1). The most common comorbidities were hypertension, diabetes, and cerebrovascular disease.

Table 1

Demographic characteristics and outcomes of patients.
Variables	Total (n = 900)	Sepsis (n = 300)	Non-sepsis (n = 600)	P value
Age(years)^a	49.5(14.6)	52.8(15.0)	47.9(14.2)	< 0.001
Male, n (%)	498(55.3%)	194(64.7%)	304(50.7%)	< 0.001
Smoking, n (%)	151(16.8%)	58(19.3%)	93(15.5%)	0.147
Alcoholism, n (%)	91(10.1%)	37(12.3%)	54(9.0%)	0.118
Admission category				0.002
Elective surgery, n (%)	703(78.1%)	216(72%)	487(81.2%)
Emergency surgery, n (%)	197(21.9%)	84(28%)	113(18.8%)
Comorbidities
Hypertension, n (%)	259(28.8%)	111(37%)	148(24.7%)	< 0.001
Diabetes, n (%)	89(9.9%)	38(12.7%)	51(8.5%)	0.048
Cerebrovascular disease, n (%)	71(7.9%)	28(9.3%)	43(7.2%)	0.256
Tumor, n (%)	42(4.7%)	12(4%)	30(5%)	0.503
Coronary heart disease, n (%)	35(3.9%)	14(4.7%)	21(3.5%)	0.393
Chalson comorbidity index^*	0(0,1)	0(0,1)	0(0,0)	0.180
APACHE II^b	16(11,20)	18(14,23)	14(10,18)	< 0.001
SOFA of ICU day1^b	4(3, 6)	5(4,6)	4(2,5)	< 0.001
GCS of ICU day1^b	10(7,11)	8(5,10)	10(7,14)	< 0.001
GOS at hospital discharge^b	4(3,5)	3(3,4)	4(3,5)	< 0.001
Death, n (%)	91(10.1%)	41(13.7%)	50(8.3%)	0.012
ICU LOS, days	6(3,13)	14(8,22)	4(3,7)	< 0.001
Hospital LOS, days^b	22(15,32)	31(21,43)	19(14,27)	< 0.001
Hospital costs (RMB, Yuan)^b	93179 (62590, 138496)	138394 (101060, 189994)	75918 (56297, 107793)	< 0.001
^adata were expressed as mean and SD; ^bdata were expressed as median and quartiles; APACHE II, Acute Physiology and Chronic Health Evaluation II; SOFA, Sequential Organ Failure Assessment; ICU, Intensive care unit; GCS, Glasgow Coma Scale; GOS, Glasgow Outcome Scale; LOS, length of stay.

A total of 509 patients (56.6%) with infection were identified, and 300 developed sepsis. The cumulative incidence of sepsis was 33.3% [95% confidence interval (CI), 30.2%-36.4%]. Nearly 2/3 of sepsis occurred during the first week after craniotomy, and over 80% of them occurred within two weeks after surgery (Fig. 2a). Fifty-five patients were with sepsis at ICU admission, and almost three-quarters of patients were diagnosed with sepsis during the first week of their ICU stay (Fig. 2b).

Sources Of Infection And Pathogens

The lower respiratory tract and CNS were the most common infection sites (Fig. 3). Lower respiratory tract infection (72.6%) and gastroenteritis (66.7%) were more likely to develop sepsis than surgical site (55.9%), CNS (48.7%), and urogenital tract infection (25.0%).

A total of 271 pathogens were isolated from 230 patients with sepsis, including 161 Gram-negative bacilli, 86 Gram-positive cocci, and 6 other pathogens (Table 2). Klebsiella pneumoniae was the most common isolated pathogen, followed by methicillin-resistant Staphylococcus aureus (MRSA), Acinetobacter baumannii, and Pseudomonas aeruginosa.

Table 2

Pathogens isolated from patients with infection and sepsis.
Pathogens	Infection(n = 509)	Sepsis(n = 300)
Gram-negative bacteria	205(40.3%)	161(53.7%)
Klebsiella pneumoniae	90(17.7%)	69(23.0%)
Acinetobacter baumannii	58(11.4%)	49(16.3%)
Pseudomonas aeruginosa	24(4.7%)	20(6.7%)
Escherichia coli	12(2.4%)	10(3.3%)
Enterobacter aerogenes	9(1.8%)	7(2.3%)
Serratia marcescens	8(1.6%)	5(1.7%)
Enterobacter cloacae	8(1.6%)	7(2.3%)
Gram negative, others^a	11(2.2%)	8(2.7%)
Gram-positive bacteria	126(24.8%)	86(28.7%)
MRSA	83(16.3%)	59(19.7%)
MSSA	14(2.8%)	13(4.3%)
Staphylococcus epidermidis	11(2.2%)	5(1.7%)
Other Staphylococcus^b	13(2.6%)	7(2.3%)
Gram positive, others^c	10(2.0%)	7(2.3%)
Other pathogens^d	9(1.8%)	7(2.3%)
^ainclude Burkholderia cepacia, Stenotrophomonas maltophilia, Proteus mirabilis, Citrobacter braakii and Klebsiella oxytoca; ^binclude Staphylococcus hominis, Staphylococcus capitis, Staphylococcus warneri and Staphylococcus saprophyticus; ^cinclude Clostridium difficile, Enterococcus faecium, Enterococcus faecalis and Streptococcus; ^dinclude Candida, Aspergillus and Chlamydia; MRSA, Methicillin-resistant Staphylococcus aureus; MSSA, Methicillin-sensitive Staphylococcus aureus.

Most of the pathogens were cultured from sputum (n = 229) and cerebrospinal fluid specimens (n = 36). In patients with lower respiratory tract infection, more G-negative bacilli (n = 157) were isolated than G-positive cocci (n = 67), and the most common isolated pathogens included Klebsiella pneumoniae (n = 65), MRSA (n = 53), and Acinetobacter baumannii (n = 45). The numbers of G-negative and G-positive cocci isolated from cerebrospinal fluid were similar, and the most common pathogens were coagulase-negative Staphylococci (n = 10) and Klebsiella pneumoniae (n = 9).

Risk Factors For Sepsis

Univariate analysis

Compared with patients without sepsis, sepsis ones were older (Table 1), and men and a higher incidence of sepsis than women. Comorbidities of hypertension and diabetes were more common in sepsis than non-sepsis patients. The sepsis group had a higher APACHE II score, a higher SOFA score, and a lower GCS than the non-sepsis group.

Patients who underwent emergency surgery had a higher incidence of sepsis than those who underwent elective surgery (42.6% vs. 30.7%, p = 0.002). Among all the causes of craniotomy, trauma was most prone to sepsis (52.0%), followed by sellar region tumors (44.6%), aneurysm (37.8%), metastatic tumors (36.4%), and intracranial hemorrhage (35.7%) (Table 3). Patients with post-operative intracranial hemorrhage (ICH) and/or hydrocephalus had an increased incidence of sepsis (Table 4).

Table 3

Indications for craniotomy, surgical site, drainage tubes, surgical relevant complications and corresponding incidence of infection and sepsis.
Indications for craniotomy	Total (n = 900)	Infection (n = 509)	Sepsis (n = 300)
Tumor
Glioma	162	97(59.9%)	56(34.6%)
Meningiomas	150	68(45.3%)	32(21.3%)
Tumors of the cranial and paraspinal nerves	62	35(56.5%)	13(21.0%)
Tumors of the sellar region	56	30(53.6%)	25(44.6%)
Mesenchymal, non-meningothelial tumors	40	25(62.5%)	13(32.5%)
Embryonal tumors	39	21(53.8%)	10(25.6%)
Metastatic tumors	11	7(63.6%)	4(36.4%)
Other tumors^a	26	10(38.5%)	8(30.8%)
Trauma	102	80(78.4%)	53(52.0%)
Cerebrovascular disease
Aneurysm	90	52(57.8%)	34(37.8%)
Vascular malformation	58	30(51.7%)	18(31.0%)
Intracranial hemorrhage	42	24(57.1%)	15(35.7%)
Occlusive cerebrovascular disease	24	10(41.7%)	7(29.2%)
Other indications^b	38	20(52.6%)	12(31.6%)
Surgery category
Elective surgery	703	380(54.1%)	216(30.7%)
Emergency surgery	197	129(65.5%)	84(42.6%)
Surgical site
Supratentorial	515	301(58.4%)	185(35.9%)
Infratentorial	385	208(54.0%)	115(29.9%)
Contamination class
clean	815	456(56.0%)	263(32.2%)
clean-contaminant	85	53(62.4%)	37(43.5%)
Post-operative indwelling drainage tube
Ventricular	50	39(78.0%)	29(58.0%)
Epidural	100	62(62.0%)	37(37.0%)
Subdural	48	37(77.6%)	20(41.7%)
Surgical cavity	108	73(67.6%)	38(35.2%)
Lumbar cistern	20	18(90.0%)	13(65.0%)
Post-operative complication
Intracranial hemorrhage	76	61(80.3%)	49(52.6%)
Epilepsy	43	29(67.4%)	19(44.2%)
Hydrocephalus	27	23(85.2%)	18(66.7%)
Cerebral infarction	25	19(76.0%)	13(52.0%)
Cerebral hernia	17	13(76.5%)	8(47.1%)
Cerebrospinal fluid leakage	6	6(100%)	3(50.0%)
^ainclude neuronal and mixed neuronal-glial tumor, choroid plexus tumor, lymphomas, tumors of the pineal region, melanocytic tumors and germ cell tumors; ^binclude dysplasia diseases, functional neurological diseases, hydrocephalus and intracranial infection.

Table 4

Risk factors for sepsis in post-craniotomy critical ill patients.
Risk factor	Univariate		Multivariate
Risk factor	OR (95% CI)	P value	OR (95% CI)	P value
Age	1.024(1.014, 1.034)	< 0.001	1.014(1.002, 1.027)	0.025
Male	1.782(1.339, 2.371)	1.782	1.681(1.1184,2.385)	0.004
Smoking	1.307(0.910, 1.876)	0.147	-	-
Alcoholism	1.422(0.913, 2.216)	0.118	-	-
Hypertension history	1.794(1.330, 2.419)	< 0.001	-	-
Diabetes history	1.561(1.000, 2.437)	0.048	-	-
Elective surgery	0.597(0.431, 0.826)	0.002	-	-
Supratentorial surgery	1.316(0.992,1.747)	0.057	1.784(1.181, 2.696)	0.006
clean-contaminant surgical wound	1.618(1.028, 2.546)	0.036	-	-
Tumors of the sellar region	1.669(0.996, 2.881)	0.064	2.188(1.089,4.397)	0.028
Trauma	2.413(1.591, 3.659)	< 0.001	-	-
Tumors of the cranial and paraspinal nerves	0.509(0.272, 0.954)	0.032	0.446(0.211, 0.943)	0.035
Meningoma	0.488(0.321, 0.741)	0.001	-	-
Postoperative hydrocephalus	4.191(1.860,9.447)	0.001	4.553(1.717,11.547)	0.002
Postoperative intracranial hemorrhage	2.181(1.210, 3.934)	0.008	-	-
Postoperative cerebral infarction	2.045(0.936, 4.469)	0.067	-	-
Postoperative epilepsy	1.623(0.874,3.012)	0.125	-	-
Duration of operation	0.899(0.847, 0.954)	< 0.001	-	-
Postoperative prophylactic antibiotics	1.272(0.963,1.680)	0.090	-	-
GCS on ICU day1
≥ 12	1		1
8 ~ 11	9.731(5.829, 16.247)	< 0.001	2.949(1.483, 5.864)	0.002
< 8	4.098(3.000, 8.030)	< 0.001	2.920(1.656, 5.147)	< 0.001
APACHE II
< 15	1		1
15 ~ 19	2.337(1.644,3.322)	< 0.001	1.356(0.888,2.070)	0.159
≥ 20	4.995(3.462,7.093)	< 0.001	1.909(1.144,3.186)	0.013
SOFA on ICU day1
< 4	1		1
4 ~ 5	3.037(2.110,4.372)	< 0.001	1.790(1.170,2.739)	0.007
≥ 6	6.363(4.334,9.342)	< 0.001	2.497(1.482,4.208)	0.001
OR, Odds ratio; CI, Confidence interval; GCS, Glasgow Coma Scale; ICU, Intensive care unit; APACHE II, Acute Physiology and Chronic Health Evaluation II; SOFA, Sequential Organ Failure Assessment.

Multivariate Analysis

Multivariate analysis showed that male sex, older in age, supratentorial surgery, tumors of the sellar region, postoperative hydrocephalus, higher APACHE II score, higher SOFA score, and lower GCS score were independent risk factors of sepsis in post-craniotomy patients. In contrast, tumors of the cranial and paraspinal nerves were associated with a lower risk of sepsis (Table 4). The Chi-square value of the Hosmer-Lemeshow test was 1.008, and the p value was 0.998.

Outcomes

Compared with non-sepsis patients, sepsis patients had higher hospital mortality rates, lower GOS at discharge (Table 1), longer ICU LOS, longer hospital LOS, and higher total medical costs.

We conducted this prospective observational study to identify the incidence, risk factors, and outcomes of sepsis in post-craniotomy critical ill patients for two years. We found the incidence of sepsis in our patients was 33.3%. Male sex, age, tumors of the sellar region, postoperative hydrocephalus, higher APACHE II score, and higher SOFA score were independent risk factors for sepsis. In contrast, tumors of the cranial and paraspinal nerves, infratentorial surgery, and higher GCS score were associated with a lower risk of sepsis. Septic patients had significantly higher hospital mortality rates, lower GOS at discharge, prolonged ICU LOS, prolonged hospital LOS, and higher total hospital costs.

Our results suggested that sepsis was common in post-craniotomy patients admitted into ICU. Compared with previous studies, the incidence of sepsis in our study was relatively lower. The difference may be mainly due to the disparity in the patient population. Most previous studies included medical and/ or surgical patients, while post-craniotomy patients were rarely involved [9, 30]. The incidence of sepsis varied among different populations[7, 8, 14, 19, 31]. Even in the same study, the sepsis occurrence rates have significant differences among medical, scheduled, and unscheduled patients[32]. Changes in definitions of sepsis could partly explain the variation of incidence. Most previous studies have defined sepsis as systemic inflammatory response syndrome (SIRS) due to infection[9, 19, 30], while we defined sepsis according to Sepsis-3 criteria. SIRS has proven to be extremely sensitive but poor specificity for sepsis[9, 22] and may overestimate the sepsis incidence. However, the incidence of sepsis in our study was still higher than those in some other studies. In the study of Berger et al.[20], 12.6% of stroke patients developed sepsis. However, they only counted sepsis episodes that occurred within the first 7 days from stroke onset. The ignoring of sepsis episodes that occurred 7 days later might have resulted in a lower sepsis incidence.

It is a pity that a review of the literature did not yield any studies that included similar patients and was comparable with ours. Some studies have described the epidemiology of infections in neurological critical ill patients [5, 33–35]. Like previous studies[5, 34, 35], pneumonia was the most prevalent infection site, and it was the most common cause of sepsis in our patients. The high incidence of pneumonia highlighted the necessity of early mobility, selective oral or digestive decontamination, subglottic secretion drainage, early tracheotomy, et al. The Society for Healthcare Epidemiology of America (SHEA) and the Infectious Diseases Society of America (IDSA) had recommended those measures [36], which are not implemented or poorly implemented in our hospital.

The incidence of CNS infection was also high in our patients. removing unnecessary drainage/ monitoring intracranial tubes[37], antibiotic prophylaxis might be helpful for the prevention of meningitis and surgical site infection after craniotomy[38, 39].

Prophylactic antibiotics were used in more than half of the patients (n = 462). The second-generation cephalosporins were the most commonly used drugs because of the reimbursement policy. However, antibiotic prophylaxis did not reduce the overall incidence of CNS infection in our study. Patients receiving prophylactic antibiotics even had a higher CNS infection rate (29.6% vs 21.2%, p = 0.004). This might be due to the higher risk of infection in those patients receiving prophylactic antibiotic therapy. Furthermore, according to the report of China Antimicrobial Resistance Surveillance System, antibiotic-resistant bacteria were prevalent in hospitals of China[40]. For example, two thirds (75.4%) of the coagulase-negative Staphylococcus isolated in 2019 were resistant to Methicillin. Multidrug-resistant (MDR) bacteria would be more prevalent in ICU than non-ICU settings[41]. Increasing risk of drug-resistant bacterial infection might have diminished the prophylactic effect of antibiotics.

Interestingly, we found that CNS and surgical site infections were less likely to develop sepsis than pneumonia and gastroenteritis. Such observation might be explained by the difference in pathogen distribution and further confirmation in large multi-center cohorts. Whether it is related to the role of the blood-brain barrier is not clear.

Similar to previous studies, we found that male sex[42], older in age[42, 43], higher APACHE II score[44], higher SOFA score[19] and lower GCS score[19] were independent risk factors for sepsis. Supratentorial surgery, tumors of the sellar region and postoperative hydrocephalus were also independent predictors of sepsis acquisition in our post-craniotomy patients, while tumors of the cranial and paraspinal nerves was associated with a lower risk of sepsis. Such information might help clinicians identify patients at high risk of sepsis, and improve their prognosis through close monitoring and active treatment.

The mortality rate of sepsis in our patients was lower than those in general ICU wards[15, 30]. Our patients were much younger and with fewer comorbidities, which might be the most important reasons for the low mortality rate. In our study, sepsis conferred a 1-fold increase in the odds of death and a 2-fold increase in the odds of prolonged ICU stay, suggesting the importance of early diagnosis and timely sepsis treatment, such as early antibiotic therapy and optimal resuscitation[45–47].

Our study has several limitations. First, this is a single-center study. Most of the patients admitted to this center were transferred from other hospitals because of severe cerebral diseases, and the results of our study might not be able to generalize to other centers. Second, the data cannot reflect the epidemiology of sepsis in all patients who underwent craniotomy as we only screened patients admitted into ICU ward. Patients with sepsis and having been treated in general wards were not included. However, those ICU unadmitted septic patients might have milder conditions and better prognoses, and they were not the ones we were interested.

Sepsis was a frequent complication in post-craniotomy critical ill patients and was associated with increased hospital mortality rate, increased hospital costs, prolonged ICU LOS, and hospital LOS. Early identification of high-risk patients based on risk factors might help early diagnosis and treatment of sepsis and ultimately improve the prognosis of those patients.

Ethics approval and consent to participate

The study was approved by the institutional review board of Beijing Tiantan hospital, with a waiver of informed consent as there was no intervention in this study (approval number: KY2019-046-01).

Consent for publication

Not applicable.

Availability of data and materials

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Competing interests

All of the authors have no affiliations with, or involvement in any organization or entity with any financial or non-financial interest in the subject matter discussed in this manuscript.

Funding

This work is supported by a grant from the Beijing Municipal Science and Technology Commission (No. Z201100005520050).

Authors' contributions

ZJ and ZJX designed the study, conducted the statistical analysis, interpreted the results, and critically revised the manuscript. ZJ and LXY contributed in data collection and analysis. CGQ, LHL, LS, SGZ, XM, YYL, and ZL contributed in data analysis, interpretation of data and drafting the manuscript. All authors read and approved the final manuscript.

Acknowledgements

We thank all the health care staff of our ICU. These individuals were not compensated for their role in the study.

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Incidence, Risk Factors and Outcomes of Sepsis in Post-Craniotomy Critical Ill Patients

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Abstract

Figures

Background

Methods

Study design

Data Collection

Definitions

Statistical analysis

Results

Incidence of sepsis

Sources Of Infection And Pathogens

Risk Factors For Sepsis

Univariate analysis

Multivariate Analysis

Outcomes

Discussion

Limitations

Conclusion

Declarations

References

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